Drugs affection the Respiratory System ( Chap 76 & 77)

Question 1

A patient with asthma will be using a metered-dose inhaler (MDI) for delivery of an inhaled medication. The provider has ordered 2 puffs to be given twice daily. It is important for the nurse to teach this patient that:

a. a chlorofluorocarbon (CFC) propellant is superior to a hydrofluoroalkane (HFA) propellant.
b. the patient should activate the device and then inhale.
c. the patient should store the MDI in the refrigerator between doses.
d. the patient should wait 1 minute between puffs.

Answer 1

ANS: D
When 2 puffs are needed, an interval of at least 1 minute should separate the first puff from the second. CFC propellants will be discontinued because of damage to the environment. The patient should begin inhaling and then activate the device. There is no need to store the drug in the refrigerator.

Question 2

A patient newly diagnosed with asthma receives prescriptions for an inhaled glucocorticoid and an inhaled beta2-adrenergic agonist. Which statement by the patient indicates understanding of this medication regimen?

a. “I should use the glucocorticoid as needed when symptoms flare.”
b. “I will need to use the beta2-adrenergic agonist drug daily.”
c. “The beta2-adrenergic agonist suppresses the synthesis of inflammatory mediators.”
d. “The glucocorticoid is used as prophylaxis to prevent exacerbations.”

Answer 2

ANS: D
Inhaled glucocorticoids are used daily to prevent acute attacks. They are not used PRN. The beta2-adrenergic agonist drugs should not be used daily; they are used to treat symptoms as needed. They do not suppress mediators of inflammation.

Question 3

A patient who uses an inhaled glucocorticoid for chronic asthma calls the nurse to report hoarseness. What will the nurse do?

a. Ask whether the patient is gargling after each dose of the glucocorticoid.
b. Request an order for an antifungal medication.
c. Suggest that the patient be tested for a bronchial infection.
d. Tell the patient to discontinue use of the glucocorticoid.

Answer 3

ANS: A
The most common side effects of inhaled glucocorticoids are oropharyngeal candidiasis and dysphonia. To minimize these, patients should be advised to gargle after each administration. Antifungal medications are used after a fungal infection has been diagnosed. Hoarseness is not a sign of a bronchial infection. There is no need to discontinue the glucocorticoid.

Question 4

A patient with asthma is admitted to an emergency department with a respiratory rate of 22 breaths per minute, a prolonged expiratory phase, tight wheezes, and an oxygen saturation of 90% on room air. The patient reports using fluticasone (Flovent HFA) 110 mcg twice daily and has used 2 puffs of albuterol (Proventil HFA), 90 mcg/puff, every 4 hours for 2 days. The nurse will expect to administer which drug?

a. Four puffs of albuterol, oxygen, and intravenous theophylline
b. Intramuscular glucocorticoids and salmeterol by metered-dose inhaler
c. Intravenous glucocorticoids, nebulized albuterol and ipratropium, and oxygen
d. Intravenous theophylline, oxygen, and fluticasone (Flovent HFA) 220 mcg

Answer 4

ANS: C
Patients using inhaled glucocorticoids should be given IV or oral glucocorticoids for acute exacerbations. During asthma flares, nebulized albuterol with ipratropium may be better tolerated and more effective. Oxygen is indicated, because oxygen saturations are low despite the increased work of breathing. Increasing the dose of albuterol and giving theophylline are not indicated. Salmeterol is a long-term beta agonist and is not useful in an acute attack

Question 5

A parent asks a nurse about growth suppression resulting from the use of an inhaled glucocorticoid in children. What will the nurse tell the parent?

a. Growth may be slowed, but eventual adult height will not be reduced.
b. The growth rate is not impaired, but overall height will be reduced.
c. The growth rate slows while the drug is used but resumes when the drug is stopped.
d. Long-term use of the drug results in a decrease in adult height.

Answer 5

ANS: A
Glucocorticoids can slow growth in children and adolescents, but they do not reduce the eventual adult height. The growth rate will return to normal within a year, even when the drug is continued. Long-term use does not affect the eventual adult height.

Question 6

A young adult woman will begin using an inhaled glucocorticoid to treat asthma. The nurse will teach this patient about the importance of which action?

a. Lowering her calcium intake and increasing her vitamin D intake
b. Participating in weight-bearing exercises on a regular basis
c. Taking oral glucocorticoids during times of acute stress
d. Using two reliable forms of birth control to prevent pregnancy

Answer 6

ANS: B
Like oral glucocorticoids, inhaled glucocorticoids can promote bone loss in premenopausal women. Patients should be encouraged to participate in weight-bearing exercises to help minimize this side effect. Patients should increase both their calcium and vitamin D intakes. Patients taking oral glucocorticoids need increased steroids in times of stress. It is not necessary to use two reliable forms of birth control.

Question 7

A 7-year-old child with asthma uses a daily inhaled glucocorticoid and an albuterol MDI as needed. The provider has added montelukast (Singulair) to the child’s regimen. Which statement by the child’s parent indicates understanding of this medication?

a. “I may notice mood changes in my child.”
b. “I should give this medication twice daily.”
c. “I will give my child one 4-mg chewable tablet daily.”
d. “This drug can alleviate symptoms during an acute attack.”

Answer 7

ANS: A
Montelukast is given as an adjunct to inhaled glucocorticoids to help prevent inflammation. Some patients have reported mood changes when taking this drug, so parents should be warned of this effect. The medication is given once daily. The dose for a 7-year-old child is 5 mg daily. The drug does not treat symptoms of an acute attack.

Question 8

A nurse is teaching a group of nursing students about the different formulations of beta2-adrenergic agonist medications. Which statement by a student indicates understanding of the teaching?

a. “Beta2-adrenergic agonists provide quick relief via any formulation.”
b. “Long-acting beta2 agonists may be used alone to prevent attacks.”
c. “Short-acting beta2 agonists are usually given by nebulizer.”
d. “Oral beta2 agonists are not useful for short-term treatment.”

Answer 8

ANS: D
Oral beta2 agonists are used only for long-term control. All formulations vary; long-acting beta2 agonists (LABAs) and oral preparations are used for long-term control, whereas short-acting beta2 agonists (SABAs) are useful for acute episodes. LABAs are used in conjunction with inhaled glucocorticoids to prevent attacks. SABAs may be given by MDI or nebulizer and usually are given by MDI.

Question 9

A patient with asthma comes to a clinic for treatment of an asthma exacerbation. The patient uses an inhaled glucocorticoid, montelukast (Singulair), and a SABA via MDI. The nurse assesses the patient and notes a respiratory rate of 18 breaths per minute, a heart rate of 96 beats per minute, and an oxygen saturation of 95%. The nurse auscultates mild expiratory wheezes and equal breath sounds bilaterally. What will the nurse do?

a. Contact the provider to request a systemic glucocorticoid.
b. Contact the provider to suggest using a long-acting beta2 agonist.
c. Evaluate the need for teaching about MDI use.
d. Question the patient about how much albuterol has been used.

Answer 9

ANS: D
To determine the next course of action, it is important to assess the drugs given before these symptoms were observed. Patients who continue to wheeze after using a SABA need systemic glucocorticoids and nebulized albuterol. If a SABA has not been used, that will be the first intervention. LABAs are not used for exacerbations. If a patient reports using a SABA without good results, evaluating the MDI technique may be warranted.

Question 10

A patient who takes theophylline (Theochron) twice daily for chronic stable asthma develops an infection and will take ciprofloxacin. The nurse will contact the provider to discuss:

a. changing to a different antibiotic.
b. reducing the theophylline dose.
c. giving theophylline once daily.
d. switching from theophylline to a LABA.

Answer 10

ANS: B
Fluoroquinolone antibiotics increase theophylline levels, so the dose of theophylline may need to be reduced to prevent theophylline toxicity. Changing antibiotics, giving the theophylline once daily, and changing to a LABA are not indicated.

Question 11

A nurse and a nursing student are reviewing the care of a 30-kg patient who will receive intravenous aminophylline. Which statement by the student indicates an understanding of the administration of this medication?

a. “After the loading dose has been given, the patient will receive 6 mg/kg/hr.”
b. “Dosing is titrated based on the serum theophylline levels.”
c. “If the patient’s serum theophylline level is less than 15 mcg/mL, the rate should be reduced.”
d. “The patient will receive a loading dose of 180 mg over 5 minutes.”

Answer 11

ANS: B
Dosing for aminophylline is based on each patient’s serum theophylline levels. The loading dose usually is 6 mg/kg; after that, the maintenance infusion is titrated according to the theophylline levels. A serum theophylline level of 15 mcg/mL is within the therapeutic range, so dosing would not need to change. The patient’s total loading dose will be 180 mg, but infusions should never be given at a rate faster than 25 mg/min.

Question 12

A child is receiving a combination albuterol/ipratropium (DuoNeb) inhalation treatment. The patient complains of a dry mouth and sore throat. What will the nurse do?

a. Contact the provider to report systemic anticholinergic side effects.
b. Discontinue the aerosol treatment immediately.
c. Notify the provider of a possible allergic reaction.
d. Reassure the patient that these are expected side effects.

Answer 12

ANS: D
The most common adverse effects of this combination drug are dry mouth and irritation of the pharynx. The patient should be reassured that these are common and minor effects. Systemic anticholinergic side effects are rare. It is not necessary to discontinue the medication. Patients with peanut allergy may have severe anaphylactic reactions, but the patient’s symptoms are not those associated with anaphylaxis.

Question 13

A patient with persistent, frequent asthma exacerbations asks a nurse about a long-acting beta2-agonist medication. What will the nurse tell this patient?

a. LABAs are safer than short-acting beta2 agonists.
b. LABAs can be used on an as-needed basis to treat symptoms.
c. LABAs reduce the risk of asthma-related deaths.
d. LABAs should be combined with an inhaled glucocorticoid.

Answer 13

ANS: D
LABAs can increase the risk of asthma-related deaths when used improperly; this risk is minimized when LABAs are combined with an inhaled glucocorticoid. LABAs are not safer than SABAs, and they are not used PRN. LABAs increase the risk of asthma-related deaths.

Question 14

A patient has just received a prescription for fluticasone/salmeterol (Advair Diskus). What will the nurse include as part of the teaching for this patient about the use of this device?

a. “You do not need good hand-lung coordination to use this device.”
b. “You will begin to inhale before activating the device.”
c. “You will need to use a spacer to help control the medication.”
d. “You will take 2 inhalations twice daily.”

Answer 14

ANS: A
The Advair Diskus is a dry powder inhaler and is activated by inhalation; therefore, hand-lung coordination is not required. There is no need for a spacer. Patients who use the Diskus take 1 inhalation twice daily.

Question 15

A patient who has been newly diagnosed with asthma is referred to an asthma clinic. The patient reports daily symptoms requiring short-acting beta2-agonist treatments for relief. The patient has used oral glucocorticoids three times in the past 3 months and reports awakening at night with symptoms about once a week. The patient’s forced expiratory volume in 1 second (FEV1) is 75% of predicted values. The nurse will expect this patient to be started on which regimen?

a. Daily low-dose inhaled glucocorticoid/LABA with a SABA as needed
b. Daily low-dose inhaled glucocorticoid and a SABA as needed
c. Daily medium-dose inhaled glucocorticoid/LABA combination
d. No daily medications; just a SABA as needed

Answer 15

ANS: A
This patient has moderate persistent asthma, which requires step 3 management for initial treatment. Step 3 includes daily inhalation of a low-dose glucocorticoid/LABA combination supplemented with a SABA as needed. A daily low-dose glucocorticoid with an as-needed SABA is used for step 2 management. A daily medium-dose glucocorticoid/LABA is used for step 4 management. Patients requiring step 1 management do not need daily medications.

Question 16

Which medication should be used for asthma patients as part of step 1 management?

a. Combination inhaled glucocorticoids/long-acting beta2 agonists
b. Inhaled low-dose glucocorticoids
c. Long-acting beta2 agonists
d. Short-acting beta2 agonists

Answer 16

ANS: D
Patients needing step 1 management have intermittent, mild symptoms and can be managed with a SABA as needed. Combination inhaled glucocorticoids/LABAs are used for step 3 management. Inhaled low-dose glucocorticoids are used for step 2 management. LABAs, along with inhaled glucocorticoids, are used for step 3 management.

Question 17

What are the results of using glucocorticoid drugs to treat asthma? (Select all that apply.)

a. Reduced bronchial hyperreactivity
b. Reduced edema of the airway
c. Reduced number of bronchial beta2 receptors
d. Increased responsiveness to beta2-adrenergic agonists
e. Increased synthesis of inflammatory mediators

Answer 17

ANS: A, B, D
Glucocorticoids act by reducing bronchial hyperreactivity and airway edema and increasing airway responsiveness to beta2-adrenergic agonists. They do not reduce the number of beta2-adrenergic agonist receptors. They help reduce the synthesis of inflammatory mediators.

Question 18

A nurse provides teaching to a patient with allergic rhinitis who will begin using an intranasal glucocorticoid. Which statement by the patient indicates understanding of the teaching?

a. “If the glucocorticoid causes burning or itching, I should use it every other day.”
b. “I should clear secretions from my nose before using the glucocorticoid.”
c. “I should use the glucocorticoid whenever I have symptoms.”
d. “I will probably develop systemic effects from the topical glucocorticoid.”

Answer 18

ANS: B
Patients using intranasal glucocorticoids should be taught to clear secretions from the nasal passages before using the medication. Intranasal glucocorticoids should be used regularly on a daily basis to achieve optimal effects and not every other day or as needed. Systemic effects from intranasal glucocorticoids can occur but are not likely.

Question 19

A child with seasonal rhinitis has used budesonide (Rhinocort Aqua) for several years. The parents are concerned that the child’s rate of growth has slowed. What will the nurse do?

a. Reassure the parents that this is an expected side effect.
b. Suggest that the parents discuss using fluticasone (Flonase) with the provider.
c. Tell the parents to administer the drug only when symptoms are severe.
d. Tell the parents that antihistamines work as well as intranasal glucocorticoids.

Answer 19

ANS: B
A worrisome systemic effect of intranasal glucocorticoids is suppression of linear growth in children. Although rare, it can occur; however, it is less likely with fluticasone and mometasone, so these two preparations are better options for children. Reassuring parents that this is an expected side effect is incorrect. Intranasal glucocorticoids should be given daily and not as needed. Antihistamines are not as effective as glucocorticoids, because antihistamines work only against one mediator of allergic inflammation.

Question 20

A patient who has seasonal allergies in the spring and fall asks the nurse about oral antihistamines. Which response by the nurse is correct?

a. “Anticholinergic effects are more common with second-generation antihistamines.”
b. “First-generation antihistamines, such as diphenhydramine (Benadryl), are more effective.”
c. “Make sure you take antihistamines only when you have symptoms to minimize side effects.”
d. “You should take oral antihistamines daily during each allergy season to get maximum effects.”

Answer 20

ANS: D
Antihistamines are most effective when they are taken prophylactically, and they should be administered on a regular basis throughout the allergy season, even when symptoms are not present. Second-generation antihistamines have fewer anticholinergic effects than first-generation antihistamines. First-generation antihistamines are not more effective than second-generation antihistamines. Oral antihistamines are not as effective when given on a PRN basis.

Question 21

A patient asks the nurse what type of medications would be most effective for treating seasonal and perennial rhinitis. Which response by the nurse is correct?

a. Pseudoephedrine (Sudafed)
b. Fluticasone propionate (Fluticasone)
c. Loratadine (Claritin)
d. Intranasal cromolyn sodium (Atrovent)

Answer 21

ANS: B
Intranasal glucocorticoids, such as fluticasone propionate, are the most effective drugs for prevention and treatment, because they prevent or suppress all the major symptoms of allergic rhinitis (congestion, rhinorrhea, sneezing, nasal itching, and erythema). Pseudoephedrine is an oral sympathomimetic used to reduce nasal congestion associated with allergic rhinitis. It has no effect on other symptoms. Loratadine, an oral antihistamine, reduces sneezing, rhinorrhea, and nasal itching only and is less effective than intranasal glucocorticoids. Intranasal cromolyn sodium is moderately effective in the treatment of allergic rhinitis, but the benefits are much less than those of intranasal glucocorticoids.

Question 22

A parent asks a nurse about giving diphenhydramine (Benadryl) to a child to relieve cold symptoms. Which response by the nurse is correct?

a. “Benadryl must be given in higher doses to provide relief for cold symptoms.”
b. “Intranasal glucocorticoids are more effective for treating cold symptoms.”
c. “Nasal antihistamines are more effective for treating cold symptoms.”
d. “Because histamine doesn’t cause cold symptoms, Benadryl would not be effective.”

Answer 22

ANS: D
Histamine does not contribute to symptoms of infectious rhinitis; therefore, antihistamines are of no use in treating cold symptoms. Giving antihistamines in higher doses does not provide relief for infectious rhinitis. Intranasal glucocorticoids are not useful for infectious rhinitis. Nasal antihistamines are not effective for treating infectious rhinitis.

Question 23

A patient admitted to the hospital has been using phenylephrine nasal spray (Neo-Synephrine), 2 sprays every 4 hours, for a week. The patient complains that the medication is not working, because the nasal congestion has increased. What will the nurse do?

a. Request an order for an oral decongestant to replace the intranasal phenylephrine.
b. Request an order for an intranasal glucocorticoid to be used while the phenylephrine is withdrawn.
c. Tell the patient to increase the dose of phenylephrine to 4 sprays every 4 hours.
d. Tell the patient to stop using the phenylephrine and begin using an intranasal antihistamine.

Answer 23

ANS: B
This patient is experiencing rebound congestion, which develops when topical sympathomimetics are used for longer than a few days. Abrupt withdrawal can stop the cycle of rebound congestion but is uncomfortable, so using an intranasal glucocorticoid while withdrawing the decongestant is recommended. An oral decongestant is not recommended. Increasing the dose of the intranasal decongestant will only compound the problem of rebound congestion. Stopping the intranasal decongestant will only increase the congestion; using an intranasal antihistamine will not help with congestion.

Question 24

A patient with allergic rhinitis is taking a compound product of loratadine/pseudoephedrine (Claritin-D) every 12 hours. The patient complains of insomnia. The nurse notes that the patient is restless and anxious. The patient’s heart rate is 90 beats per minute, and the blood pressure is 130/85 mm Hg. The nurse will contact the provider to:

a. discuss using an intranasal glucocorticoid and loratadine (Claritin).
b. report acute toxicity caused by pseudoephedrine.
c. suggest using an agent with a sympathomimetic drug only.
d. suggest using a topical decongestant to minimize systemic symptoms.

Answer 24

ANS: A
This patient is showing central nervous system (CNS) and cardiovascular side effects of the pseudoephedrine. A better option would be to use single-ingredient products for each symptom; an intranasal glucocorticoids and an oral antihistamine are considered first-line treatments. This patient is demonstrating adverse effects but not acute toxicity. Using a sympathomimetic agent would increase the adverse effects, because pseudoephedrine is a sympathomimetic drug. Topical decongestants are not first-line drugs for allergic rhinitis.

Question 25

What is ipratropium bromide (Atrovent)?

a. A cholinergic agent used for perennial rhinitis
b. An anticholinergic used for allergic rhinitis and colds
c. A medication that is used only in patients with asthma
d. A drug that is inappropriate for use in patients with allergic rhinitis

Answer 25

ANS: B
Ipratropium bromide is an anticholinergic that is indicated for allergic rhinitis, asthma, and the common cold. The drug reduces rhinorrhea. Ipratropium bromide is an anticholinergic. In addition to asthma, ipratropium bromide can be used for allergic rhinitis and the common cold. Ipratropium bromide can be used for allergic rhinitis.

Question 26

A parent asks a nurse to recommend an intranasal decongestant for a 6-year-old child. Which response by the nurse is correct?

a. “Decongestants are too sedating for children and should not be used.”
b. “Decongestants should not be given to children under 7 years old.”
c. “Decongestant drops are recommended instead of decongestant sprays.”
d. “Decongestant sprays should be used no longer than 5 to 10 days.”

Answer 26

ANS: C
Decongestant drops are recommended for children, because the number of drops can be controlled precisely. When sprays are used, the amount given is not well controlled. Decongestants cause CNS excitation. Decongestants may be given to children over the age of 4 years. Intranasal decongestants should not be used for longer than 5 days.

Question 27

A patient with a cough has been advised to use guaifenesin. The patient asks the nurse to explain the purpose of the drug. The nurse will explain that guaifenesin:

a. dries secretions to help suppress coughing so patients can rest.
b. helps stimulate the flow of secretions to increase cough productivity.
c. helps to relieve chest pain associated with a cough.
d. stimulates the body’s natural immune responses.

Answer 27

ANS: B
Expectorants stimulate the flow of respiratory tract secretions to improve cough productivity. Guaifenesin does not dry secretions, because it does not have anticholinergic effects. Guaifenesin does not alleviate pain associated with cough. Guaifenesin does not stimulate immune responses.

Question 28

A child who has perennial allergic rhinitis has been using an intranasal glucocorticoid. The provider has ordered montelukast (Singulair) to replace the glucocorticoid, because the child has frequent nosebleeds. When teaching this child’s parents about montelukast, the nurse will include which statement?

a. “Montelukast is also effective for treating infectious rhinitis.”
b. “Montelukast may cause behavior changes in your child.”
c. “Montelukast will treat both congestion and rhinitis.”
d. “Montelukast works best when combined with a topical decongestant.”

Answer 28

ANS: B
Montelukast can cause rare but serious neuropsychiatric effects in patients, and parents should be warned of this possibility. It is not useful for treating infectious rhinitis. It does not affect congestion. It is not necessary to add a topical decongestant when using this drug for allergic rhinitis.

Question 29

A 7-year-old child has a cough, runny nose, congestion, and fever, and the parents ask the nurse to recommend an over-the-counter product. Which response by the nurse is correct?

a. “Any product will be effective when combined with vitamin C and zinc.”
b. “It is best to use single-agent medications to treat individual symptoms.”
c. “The fever indicates that your child may need an antibiotic; you should call your provider.”
d. “You should ask your provider to prescribe a combination product that will treat multiple symptoms.”

Answer 29

ANS: B
Combination medications may provide ingredients that are not needed or may provide ingredients that are either excessive or subtherapeutic. It is best to use single-agent drugs to treat individual symptoms. The efficacy of vitamin C and zinc for treating colds in children has not been established. Fever may accompany viral respiratory infections and not necessarily bacterial infections that need an antibiotic.